Buprenorphine is a partial opioid agonist approved for clinical use by the United States Food and Drug Administration (FDA) in 2002. As a Schedule III controlled substance, a mandatory certification from the Drug Enforcement Administration (DEA) is needed to provide prescriptions for buprenorphine for opioid dependence. Is acquiring a certification right for your practice, and what does buprenorphine treatment entail from the clinician’s perspective?
These questions were addressed in a presentation by Arwen Podesta, MD, DFASAM, DFAPA, ABIHM, adjunct professor, Tulane University and Louisiana State University, and psychiatrist of Podesta Wellness in New Orleans, Louisiana at the 2019 Psych Congress meeting.
Medication-Assisted Treatment: Current Guideline Recommendations
Opioid use disorder is a chronic disease, for which medication-assisted treatment (methadone, buprenorphine, or naltrexone) is safe and effective when used appropriately. Pharmacotherapy should be considered in all cases of opioid-use disorder, and patients should be advised how and where to obtain medication-assisted therapy. Individuals receiving medication-assisted therapy are considered to be in recovery.
In addition to appropriateness for the patient’s needs, clinicians should consider patient preference, access to treatment (eg, vicinity to a clinic), and risk for diversion when selecting pharmacotherapy for patients with substance use disorder.
Barriers to Buprenorphine Treatment
Dr Podesta’s presentation highlighted that only 5% of physicians have the required waiver to prescribe buprenorphine. In one study, just 28% of physicians with recently acquired waivers were actually found to be prescribing buprenorphine. Further, 60% of rural areas lack a waivered physician.
Coupled with the overarching stigma attached to opioid dependence, these factors exacerbate a lack of access to medication-assisted treatment. Good outcomes are achievable in substance use disorder in the long term, but are contingent on adequate treatment access and duration. Short-term detox is not treatment, a point that should be emphasized to the general public, according to Dr Podesta.
Implementing Buprenorphine Into Your Practice
The average daily dose of buprenorphine is 8 to 24 mg. It is administered as a daily sublingual film, sublingual tablet, buccal film, 6-month subdermal implant, or extended-release injection. As a partial agonist, it is safer than other opioids (in terms of overdose) and confers less withdrawal symptoms compared with opioid receptor antagonists. It is recommended that a formulation containing both buprenorphine and naloxone is prescribed for the treatment of opioid dependence.
Importantly, clinicians should be aware of their respective state’s prescription drug monitoring program requirements before and during buprenorphine treatment. These regulations apply differently when buprenorphine is prescribed for opioid use disorder vs pain management. Buprenorphine products that are indicated for pain management by the FDA should not be prescribed for the treatment of substance use disorder.
Before prescribing buprenorphine, clinicians must confirm a diagnosis of opioid use disorder with information from patient history or treatment records; signs of withdrawal, track marks, or abscesses; and drug screens.
With early treatment, accountability is key: consider short-term prescriptions and collaboration with a pharmacy team to create a plan for dispensing.
Dr Podesta also emphasized the importance of strict documentation for patient care, potential DEA visits (which are required among certified prescribers), mitigation of legal risk, and insurance purposes. Patient signatures should be acquired for informed consent/treatment agreement.
Treatment Maintenance: How Long Should Patients Be on Buprenorphine?
There is no single answer for how long patients should receive medication-assisted therapy, explained Dr Podesta. In her practice in New Orleans, buprenorphine treatment duration has ranged from months to years.
Regular medication counts, confirmation of attendance in peer support and counseling, and random urine drug screenings are recommended during buprenorphine treatment maintenance. Patients develop dependence to buprenorphine, so withdrawal will occur if a patient stops taking the medication abruptly. Protocols are available to guide the transition from buprenorphine to naltrexone.
With medication-assisted therapy, psychosocial treatment and other tools to increase accountability should be offered to patients, including supportive medication monitoring; individual or group counseling; and 12 Step, Narcotics Anonymous, or other mutual support groups and recovery training programs.
How to Become a Waivered Practitioner
There is enormous need for well-trained providers who are educated in treating opioid use disorder. According to data from 2016 and 2017, >130 people die every day from opioid overdose. More recent data indicate that this number is closer to >200 deaths daily, according to Dr Podesta.
For physicians who do not have a certification in addiction medicine, an 8-hour waiver training is required to offer buprenorphine and naloxone to patients who are dependent on opioids. For nurse practitioners and physician assistants, the training is 24 hours. Capacity to refer patients to counseling and ancillary services is also required and must be demonstrated to obtain the waiver.
Waiver trainings are available from the American Society of Addiction Medicine, American Academy of Addiction Psychiatry, and Substance Abuse and Mental Health Services Administration Providers Clinical Support System.
As for why a clinician may want to consider obtaining a buprenorphine certification, Dr Podesta explained, “Recovery is beautiful for patients and families; being the provider of it can replenish the practitioner.”
For more coverage of Psych Congress 2019, click here.
Disclosure: Dr Podesta is a consultant for Kaleo, Pear Therapeutics, and JayMac Pharmaceuticals and is part of the speaker bureau for Alkermes, Orexo, and US WorldMeds.
Podesta A. What you need to know about buprenorphine treatment for opioid use disorder. Presented at: Psych Congress 2019; October 3-6, 2019; San Diego, CA.